Basic Information
| Provider Information | |||||||||
| NPI: | 1548495294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAILESILASIE | ||||||||
| FirstName: | DEREJE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 708760 | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840708760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013529500 | ||||||||
| FaxNumber: | 8013527976 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 SUNSET LN | ||||||||
| Address2: | |||||||||
| City: | CULPEPER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 227013917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408294266 | ||||||||
| FaxNumber: | 5408298898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2009 | ||||||||
| LastUpdateDate: | 05/26/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101245421 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.